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Monday, 11 September 2017

Value Based Medicine (VBM)

Evidence-based medicine (EBM), after 25 years, has generated substantial advances in research methodology and has made it possible to distinguish more clearly between good and bad treatments, to identify biases of any order and even evidence of conflicts of interest between research and industry. However, a group of English authors (The importance of values in EBM, Kelly MP 2016) believes that, despite the uncontested advances, EBM has put too much focus on the technical aspects and has forgotten that values ​​have a lot of influence at all stages of the evidence-building processes.

What do we mean when we talk about values?

Science strives to understand the world as it is, but conversely, values ​​are what humans reflect upon. Seen this way, the conflict is served and, therefore EBM should learn to navigate better between these two waters according to the authors of the article quoted below, "Values may act as heuristics – shortcuts in our thinking of which we are barely aware – which get us to quick answers to complicated problems. They form the lens through which we perceive and act on our world. Values are often tricky to pin down because they are such a pervasive part of things we take for granted. A necessary first step towards achieving this is to make our values as explicit as we can, so that we can reflect on them individually and deliberate on them collectively".

Some notes on the influence of values ​​in the process of evidence:

a) The key question. There’s a magical thought about a supposed ethical neutrality of evidence, while the question of values ​​remains in the hands of clinical practice. Kelly et al, on the other hand, emphasize the influence that values ​​have from the beginning, from the moment when the key question is asked. Why decide to test the effectiveness of a particular drug? Could it be because it has more commercial possibilities? What about the other causes? Are there more shortcomings?

b) The choice of methodology. Randomized double-blind clinical trials are preferred, but the clinic often requires more knowledge about effectiveness in the real world and, at this point, the methodology is not neutral either. We must claim that the adoption of pragmatic studies is not a sign of scientific weakness, but an empirical approach to clinical practice.

c) Shared decisions. When a physician proposes several therapeutic alternatives to a patient, the evidence plays a key role, but in itself is insufficient, because people have their own way of seeing things, and additionally the clinic is actually full of interactions between morbidities or among others social or cultural circumstances, an area where EBM has not yet infiltrated.

d) Professionalism and clinical practice. Doctors and nurses, clinical skills aside, have their own sets of values: a religious way of looking at life, a defensive vision of clinical practice, an overly interventionist attitude, to give just a few examples. In addition, doctors and nurses work under the pressure of certain circumstances, which are not neutral either. For example, it’s well known that limitations on time dedicated to patient dedication may encourage the prescribing of more medications or requests for further testing.

The new evidence-based medicine (EBM), i.e., value-based medicine (VBM), should, in summary, reflect on two basic problems: a) science cannot be isolated from the values ​​of scientists as people, nor from the values ​​of the industry that drives them, nor those of the politicians who subsidize them, and b) EBM should go beyond efficacy studies and dig deeper on clinical effectiveness and cost-effectiveness, so it should know how to distance itself from the research parks, and focus on providing more methodology in the practice of first-line medicine.